Chronic Fatigue Syndrome: Implications for Women and Their Health Care Providers During the Childbearing Years

Peggy Rosati Allen, CNM, WHNP, MS, LCCE


J Midwifery Womens Health. 2008;53(4):289-301. 

In This Article

Diagnosis, Symptoms, and Comorbid Conditions

The diagnosis of CFS is challenging for a variety of reasons: CFS lacks a diagnostic laboratory test or biomarker; many people with CFS do not look sick despite profound disability; symptoms may vary from person to person and even day to day in an individual; and fatigue and other CFS symptoms are common in many other illnesses. Thus, CFS is a diagnosis of exclusion.[4]

A case definition of CFS was internationally accepted and published in 1994 and continues to provide the standard for diagnosis of CFS in adults.[24] The International Chronic Fatigue Study Group, a committee of CFS experts, advocates revisions in the application of the current case definition to research because aspects of the case definition are ambiguous and have contributed to the heterogeneity and difficulty in studying the CFS population.[25] In 2006, a pediatric CFS case definition and a reliable assessment instrument to aid clinicians in the diagnosis of CFS in young people was published.[26]

To be diagnosed with CFS, a person must experience a significant reduction in their previous ability to perform one or more aspects of daily life in work, school, household, or recreation. All people suffering from CFS experience severe, all-consuming mental and physical fatigue that is not relieved by rest. The fatigue can be worsened by minimal physical or mental exertion. Although the formal diagnosis of CFS requires fatigue of at least 6 months' duration in adults and 3 months in children, the entire symptom complex must be considered rather than fatigue alone in making a diagnosis.[4,26]

According to the CDC, a thorough medical history, physical examination, mental status examination, and laboratory tests must be conducted to identify any underlying or contributing conditions that require treatment. Figure 1 shows an algorithm for the diagnosis of CFS in adults, while Table 1 shows some exclusionary laboratory tests.

Figure 1.

Algorithm for the Diagnosis of Chronic Fatigue Syndrome. Reprinted from Centers for Disease Control and Prevention Web site (

Orthostatic intolerance, an umbrella term that includes the conditions of neurally mediated hypotension and postural orthostatic tachycardia syndrome, commonly occurs with CFS, particularly among adolescents.[27,28,29,30] Neurally mediated hypotension occurs when the autonomic nervous system, which controls heart rate and blood pressure response, misinterprets what the body needs during an upright posture and sends a message to the heart to slow down and lower the blood pressure, the opposite of what the body needs. Postural orthostatic tachycardia syndrome is defined by an increase in heart rate of more than 30 beats per minute or an increase in heart rate exceeding 120 beats per minute within 5 to 10 minutes when changing from a supine to upright position.[29] The symptoms of orthostatic intolerance are listed in Table 2 .

Factors that cause orthostatic intolerance in CFS are poorly understood and may include complex interactions between adrenal hormones, HPA-axis dysregulation, and autonomic dysfunction of heart rate, heart muscle contraction and relaxation, peripheral vasodilation and constriction, reduced cerebral perfusion, and volume depletion.[27] Cardiology testing with the tilt-table test can aid in the diagnosis of orthostatic intolerance with CFS.[28,30]

Many comorbid conditions with CFS have US Food and Drug Administration (FDA)-approved drugs or evidence-based treatment options. In addition to the orthostatic syndromes of neurally mediated hypotension and postural orthostatic tachycardia syndrome, these conditions include metabolic syndrome, hormone imbalances or dysregulation, vitamin D and vitamin B12 deficiencies, irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and celiac disease.[31]


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